The availability and generosity of medicaid home & community based services for economically vulnerable older adults: State differences and their relationship to end of life outcomes
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- Tez No: 780475
- Danışmanlar: DR. TARYN LİNDHORST
- Tez Türü: Doktora
- Konular: Sosyal Hizmet, Social Work
- Anahtar Kelimeler: Belirtilmemiş.
- Yıl: 2021
- Dil: İngilizce
- Üniversite: University of Washington
- Enstitü: Yurtdışı Enstitü
- Ana Bilim Dalı: Belirtilmemiş.
- Bilim Dalı: Belirtilmemiş.
- Sayfa Sayısı: 182
Özet
Most older adults express a wish to age and die in their own homes, yet without a support system, dying at home can be impossible due to high needs for assistance with self-care, mobility, symptom management and day-to-day functioning at the end of life. The care needs of economically vulnerable, community dwelling older adults are addressed by Medicaid 1915(c) waivers which allow Medicaid funds to be used to provide home and community–based services (HCBS). Medicaid 1915(c) waivers reach the most economically vulnerable older adults – also known as“dual eligible”older adults as they are qualified for both Medicare and Medicaid. HCBS waivers allow states to provide services that can help with symptoms, housework, daily activities, caregiver support and with home safety. There is no federal policy regulating the services provided by Medicaid waiver programs and 1915(c) waivers are offered at the discretion iv of the states. As a result, states vary dramatically in the availability of the suite of services provided as well as the level of funding, or generosity of these services. These state-level differences may create disparities in the end-of-life experiences among dual eligible older adults based on the state they live and die in. Aims: This dissertation investigated 1) state variation in Medicaid 1915(c) waiver availability and generosity of HCBS to dual eligible older adults, and 2) the association between state variation in availability and generosity and end of life experiences. Methods: Three papers were written to answer the aims of this dissertation. First, a policy analysis was conducted to explore availability and generosity of 1915(c) waivers utilizing three datasets: 1) waiver application documents located at CMS.Medicaid.org, 2) the Medicaid Analytic Extract - Other Services (MAX-OT) dataset, and 3) Genworth State Cost of Care Survey 2013. Analysis of these datasets resulted in summative descriptions of 8 state-level indicators for availability and generosity of HCBS. For the second and third papers, the National Health and Aging Trends Study (NHATS) (Wave 2-7, 2012-2017) was utilized in addition to state-level data summaries created for the policy analysis. For paper 2, regression analyses were used to determine the effect of waiver availability and generosity on unmet end of life needs. For paper 3, regression analyses examined the effect of HCBS on the quality of life reported at the end of life. Results: Substantial variation exists between states in available services, coverage for target groups, service slots available, ability to direct participants' own care and generosity of services. Paper 2 found that 40.26% of the sample had unmet needs for self-care and mobility activities Unmet need for assistance was associated with lower availability of HCBS and less generosity for homemaker services, having dementia and not having participant direction option. Paper 3 found that 56.07% of low-income respondents reported having v a low quality of end of life. Lower quality at the of end of life was associated with fewer available HCBS slots, living alone, higher numbers of chronic diseases and receiving hospice during the last month of life and. Discussion: Community dwelling dual eligible older adults nearing the end-of-life experience unmet needs with self-care and mobility activities and low quality of end of life, such as high symptom burden and lower functioning. The findings indicated that 1915(c) waivers could tailor their services for older adults at the end of life due to their higher risk for unmet needs and lower quality of end of life. Generosity for the services and slots available for dual eligible older adults were also associated with end-of-life experiences of this sample, therefore Medicaid waivers should increase their generosity and slots to better meet the needs of economically vulnerable older adults at the end of life.
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